Thursday, August 2, 2012

I just got home from the UK where I attended the three-day IEDTA meeting and a three-day ISTDP immersion course taught by Jon Frederickson and Rob Neborsky. Both were excellent.

Over the past several years, I have been watching a spectrum of ISTDP practice and trying to understand their common elements and differences are. Other than at conferences, most of the work I've been exposed to so far has been from Allan Abbass and Jon Frederickson. The immersion was the first chance I had to see Rob Neborsky's work in the style that he and Josette ten Have-de Labije have developed.

Trying to fit their work together with what I already understood led me to a new way of thinking about it, which I found helpful, and which I'll describe here. There are no new concepts here, but I think it's simple, direct terminology that can help us understand what people are doing from a unified standpoint.

Executive summary:

(1) There are two kinds of defenses: affect defenses and relationship defenses. Affect defenses are used to avoid particular feelings. Relationship defenses are used to avoid or sabotage an open, caring, constructive relationship either by avoiding relationship altogether or by promoting a dysfunctional relationship.

(2) There are relationship defenses toward others and relationship defenses toward the self.

At more length:

(1) I'm sorry to say that I haven't yet absorbed Rob and Josette's book so I can't comment in detail about the relationship between what I'm saying and their work, but the distinction between affect defenses and relationship defenses is similar if not identical to what they call "cellar-door" defenses and "front-door" defenses. (They also use the more formal terms "defense at the level of stimulus" and "defense at the level of response," which I must admit I find both very unclear and very cumbersome).

Most of the emphasis in psychodynamic theory has been on affect defenses, but relationship defenses are extremely important and have been comparatively neglected. When Davanloo divides defenses into "major defenses" and "tactical defenses," he is, roughly speaking, talking about a division between affect defenses and relationship defenses (with the therapist, in the case of tactical defenses). He is very explicit that it is hard to draw a bright line between them, that tactical defenses often occur in the service of a major defense, and that it is often unclear at the beginning to what extent something is a relationship vs affect defense (e.g. when a patient says that they can't remember something this could be lying [relationship defense] or repressing [affect defense]—and a whole continuum in between). In ISTDP theory, "resistance against experiencing feeling," refers to affect defenses; "resistance against emotional closeness" and transference resistance refer to relationship defenses.

(2) ISTDP has been explicit in addressing relationship defenses with others (particularly the therapist), but relationship defenses with the self have been addressed more implicitly. Of course, when Davanloo says "I have to ask myself, 'Why would a person do that to themselves,'" he is addressing a certain sort of relationship that the patient has established with him/herself. Self-criticism, self-neglect, self-sabotage, indifference to the self etc. can all be seen as enacting a certain relationship with the self. I have heard Jon talking about how patients avoid intimacy with themselves.

What Josette has shown us is that these relationship defenses with the self can be addressed first, for example by pointing out the patient's self-neglect in terms of awareness of anxiety. The point behind this particular language is that wherever you start: pressure to feeling, observing anxiety, etc. you are doing the same thing: immediately addressing the destructive defenses that come up, which leads to a rise in complex transference feelings, etc. Of course that's not say that all approaches are equally good in all situations, just that we can understand all the different options under the ISTDP umbrella.

About Me

I am a psychiatrist in private practice in Belmont, MA, USA, and a Lecturer (Part-Time) in Psychiatry at Harvard Medical School. The main focus of my practice, teaching, and writing is Intensive Short Term Dynamic Psychotherapy (ISTDP).